OHSU study raises concerns about health care access impact of OHP co-payments
Cutbacks in the Oregon Health Plan (OHP) including establishment of a $50 co-payment for Emergency Department (ED) visits led to a 14 percent drop in ED use among OHP Standard enrollees, according to Oregon Health & Science University (OHSU) study results presented this week in Washington, D.C., at the American College of Emergency Physicians Research Forum.
"Our first reaction to the results was excitement at the cost savings from reduced ED use, but when we put these findings in context, the news was not so good," said lead investigator Robert A. Lowe, M.D., M.P.H., director of the OHSU Center for Policy and Research in Emergency Medicine and associate professor of Emergency Medicine in the OHSU School of Medicine. "Absent improved safety net access outside the ED, it is likely that these patients did without care, rather than getting less expensive care."
The study found that enrollees in OHP Standard used the ED 14 percent less after they became subject to the co-payments in March 2003, while enrollees in OHP Plus, who were not affected by the co-payments and other cutbacks, demonstrated no change in ED use.
"ED use is often a barometer of the status of our health care system," said Lowe. "Identifying ED trends helps us to understand when health care access issues may be facing a crisis point."
"This study's results raise timely questions," said Charles A. Gallia, Ph.D., evaluation research coordinator for OMAP, and study co-author. "For instance, did the benefit reduction and increased co-pays have the unintended consequence of suppressing use of some preventive health care services, even those that would best be treated in an ED setting, thereby making the long-term costs even higher?"
In 1994, Oregon expanded its Medicaid program from 300,000 eligible people to an additional 100,000 low-income people. The OHP was widely hailed as a national model to enhance access to medical care for underinsured and uninsured people. A premise of the plan was that access to primary and preventive health care services would reduce long-term costs thereby allowing the state to afford to provide health care coverage to more people.
In 2003, faced with budget shortfalls, the state instituted a stricter premium policy resulting in a substantial decline in enrollment. Also, co-payments were added including a $50 co-payment for an ED visit.
Based on statewide data compiled and provided by the Oregon Office of Medical Assistance Programs (OMAP), the OHSU study compared ED use between 2001 and 2003 - before and after OHP cutbacks and during the time when the co-payments were in effect. Since then, ED co-payments have been ruled illegal and are no longer required.
Follow-up studies will refine the results to provide a better understanding of whether the reduced ED use was for minor problems or for conditions that, without prompt treatment, could endanger health, and whether ED use changed once again after the co-payments ended.
These studies will help understand the health care access implications of a new round of OHP restrictions now under consideration by OMAP for 2006 and beyond, and may provide guidance to other state and federal policymakers considering cost-sharing mechanisms in the current Medicaid budget reduction discussion.
"At OHSU we can't solve the crisis of access for the state at the clinical level although we can, and will continue, to do our share in that regard," said Peter Kohler, M.D., OHSU president. "Where we can make a major contribution is in the research and health policy arenas. There are many researchers at OHSU striving to provide new data and insight to aid decision-makers working toward systemic health care reform."
"Impact of Cutbacks in the Oregon Health Plan on Emergency Department Use: A Statewide Study" is published as an abstract in the Annals of Emergency Medicine, September 2005. This research was supported by a Riggs Family/Emergency Medicine Foundation Health Policy Research Grant.